Tag Archives: Psychiatry

OK, it doesn’t have the same ring as the traditional punch line, but for many patients the fear of being slipped in a scanner surrounded by the clicking and banging sounds of an MRI ranks right up there with a root canal.

Rather than sedating these patients, a radiology group in France has been offering hypnosis on a daily basis since 2004.

Over a 15-month period, 45 patients were identified as being claustrophobic and refused the scheduled MRI, including four patients who experienced a panic attack.

All 41 patients who agreed to undergo a brief 3- to 5-minute single session of hypnosis just before the MRI completed the exam, including those with panic attacks.

Conversely, none of the four patients who refused hypnosis were able to withstand the procedure, radiologist and co-author Dr. Bruno Suarez reported at the Radiological Society of North America meeting.

Dr. Bruno Suarez

“The more a patient is claustrophobic, the more hypnosis is efficient,” Dr. Suarez, with L’Hôpital Privé de Thiais in the outskirts of Paris, said in an interview. “For us it’s a surprise. It’s a very interesting technique.”

The technique is based on the late American psychiatrist Dr. Milton Erickson’s approach to hypnosis, but modified to integrate the repetitive noise of the MRI. Patients are given a tour of the MRI room, assured that the scanner and its magnets are safe and prompted to mentally recall a pleasant memory involving a repetitive noise while the MRI exam is performed.

During hypnosis, the brain is more susceptible to suggestions, Dr. Suarez said, noting that a Belgian study showed that hypnosis reduces the perception of pain by 50%.

Hypnosis requires a good memory and language skills, so it’s not used on those under five years of age or those with dementia or Alzheimer’s, he added.

So far, a radiologist, two MRI technicians and even the two office receptionists have been trained in the technique.

Marc Andre Fontaine (left) and Dr. Suarez

“I like the contact with the patient, and I want the best results for the patient,” MR technician and co-author Marc Andre Fontaine said in an interview.

The 45 patients in the series represent just 1.4% of the roughly 3,300 patients seen by the group over the 15 months, but the appeal of the drug-free method has attracted referrals from other centers. It’s also a big financial boon due to shorter exam times, fewer appointment cancellations and no procedural side effects, Dr. Suarez said.

A recent study by interventional radiologist and hypno-analgesia pioneer Dr. Elvira Lang reported that self-hypnotic relaxation added an extra 58 minutes to the room time for an outpatient radiologic procedure, but still saved $338 per case compared with standard IV conscious sedation.

That’s a big savings for just getting patients to relax with a few words, especially when you consider that nine out of ten patients are probably already muttering something under their breath during their MRI.

The first psychiatric hospitals in the United States brought a revolutionary perspective toward people with mental illness — the idea that the aim was to cure, not to subdue. McLean Hospital’s celebration of its 200th year in 2011 is great fodder for mulling over the psychiatric care of the past, and for trying to imagine psychiatric facilities of the future.

The third oldest psychiatric hospital in continuous operation in the United States, McLean was founded on the same day as Massachusetts General Hospital in 1811, but opened its doors 3 years before the general hospital, Adriana Bobinchock told me at the American Psychiatric Association annual meeting. Today, McLean Hospital is the largest psychiatric affiliate of Harvard Medical School and partners with Massachusetts General and Brigham and Women’s Hospitals, said Ms. Bobinchock, director of public relations for McLean Hospital.

The only older continuously operating psychiatric hospitals in this country may be Eastern State Hospital, founded in 1773 in Williamsburg, Va., and Spring Grove Hospital Center, founded in Catonsville (near Baltimore), Md. in 1797.

The old McLean Asylum, mid-1880s. (Image courtesy of McLean Hospital)

A brief history of McLean Hospital contains an eclectic collection of “firsts.” It opened the first psychiatric school of nursing in 1882. It was the first U.S. psychiatric hospital to open research laboratories. And it’s the origin of the nursery song, “Mary Had a Little Lamb,” which was inspired by one Mary Sawyer, an attendent at the McLean Asylum for the Insane (as it was then called) in 1832 who had, indeed, been followed by a lamb to school.

Animals played an important role at the asylum, which evolved into the hospital. Until as recently as 1944, it operated as a nearly self-sustaining community, with a farm, a blacksmith, and an upholstery shop. The asylum originally was located in bucolic Somerville, Mass., because the quiet, rural environment was thought to be therapeutic. Before long, urban encroachment wrecked the peace, including two railroad lines that cut through the grounds, so the facility moved to new grounds in Belmont, Mass., where it remains today. The hospital has grown from seeing 13 patients in its first 3 months to now admitting more than 9,000 adults and children each year to inpatient and residential levels of care, as well as providing more than 58,000 day-treatment and outpatient visits per year in seven satellite programs around Massachusetts.

The psychiatric diagnoses of 1811 bear little resemblance with today’s diagnoses of mental illnesses. Watch the brief video interview with Ms. Bobinchock (below) to hear some of the reasons patients first came to McLean. It all makes me wonder how we’ll conceptualize mental illness another 200 years down the road. This year, when proposed revisions in the DSM-V will greatly rearrange some of our current diagnostic categories, it’s not hard to imagine that we’ll be using very different descriptions of mental illness even 50 years from now, much less 200.

And I wonder if some of the characteristics of yesteryear’s asylums might return in the future. Will a connection with nature be fostered as a healing force? Will communities increasingly be expected to be self-sustaining? Will we have cures for the worst psychiatric illnesses, so that no ever need be “subdued”?

Many psychiatrists of, ahem, a certain age (say, over 30) have been caught by surprise by the reach of online and social media. With the explosion in use of the Internet, e-mail, Google, Facebook, Twitter, LinkedIn, and many other ways to find out information about someone, there’s no such thing as privacy any more. That creates a new set of modern problems for psychiatrists who walk a fine line between building a therapeutic alliance with patients and keeping a professional distance.

Image captured by flickr user smemom87.

I sat in on a fascinating group discussion at the annual meeting of the American College of Psychiatrists to hear how professionals are grappling with these issues. Look for a more detailed report soon in Clinical Psychiatry News. What surprised me is that even some very young psychiatrists who grew up so immersed in online and social media that they seem like part of the natural environment have been surprised by the professional ramifications of the long reach that these tools give to patients.

Some of the challenges are old problems in a new form, it seems. Setting limits on patients’ e-mail contact with psychiatrists is similar to setting limits on phone contact in some ways, but magnified. The Internet and e-mail can be both helpful and problematic in their work, psychiatrists said. The biggest potential land mines are in the social media. What happens when a patient wants to “Friend” a psychiatrist who is on Facebook? No matter how the psychiatrist responds, there’s grist for the psychoanalytic mill. Transference becomes a bigger issue. Even using the highest privacy settings, non-Friend visitors to your page can glean information about you, your “Friends,” and potentially your family. Perhaps not surprisingly, only a handful of psychiatrists in the room said they were on Facebook. And Internet dating? Look out.

Does that mean psychiatrists must be technological hermits, never to enjoy the interconnectedness that social media supply to everyone else in society?

These are all weighty questions that usually have no right or wrong answer. The American Association of Directors of Psychiatry Residency Training (AADPRT) just released new curricula to guide psychiatrists-in-training in discussing these issues, so that they can anticipate the potential consequences of the decisions they make about use of online tools and social media. See my full story for details.

The curricula are available only to AADPRT members, though some of the resources in them may be made available to the general public in the future, said AADPRT President Dr. Sheldon Benjamin. Meanwhile, you can hear him discuss these topics in an AADPRT podcast interview with Dr. Sandra M. DeJong, chair of the Association’s Task Force on Professionalism and the Internet.

I’d love to hear from clinicians of any specialty who are reading this (but especially psychiatrists) — do you use social media? Are they worth the potential professional problems? And will you Friend me? Leave a comment, and let us know.

Recent evidence suggests that traumatic brain injury is a chronic, rather than an acute condition — which can have psychological effects on patients and their families indefinitely. Dr. David K. Menon of the University of Cambridge talked with our reporter Heidi Splete about the challenges of assessing and treating TBI as a chronic disease at the annual meeting of the American Association for the Advancement of Science.

A panel of experts at the the annual meeting of the American Association for the Advancement of Science said that preliminary research into the use of deep brain stimulation (DBS) has shown promise for the treatment of a number of psychiatric disorders, including depression and obsessive-compulsive disorder. Despite the possibilities that treatment with DBS may offer, caution is needed, according to Dr. Benjamin Greenberg of Brown University, who spoke with our reporter Esther French.

My strong advice would be that psychiatrists first need to think about whether they’ve really exhausted all conventional treatments … and there are a lot of treatments that one could potentially use, including one thing that is often neglected, which is residential behavioral therapy.

Dr. Greenberg estimates that it takes about 5 years to exhaust all other treatment possibilities but at that time, DBS becomes a treatment option. DBS is currently used with success to treat movement disorders.

Plenty of evidence suggests that reducing chronic stress can improve health, but preliminary data in mice suggest that controlling chronic stress can help those inclined to baldness keep their hair. Dr. Lixin Wang of the University of California, Los Angeles, and colleagues observed the possible effects of blocking corticotropin-releasing factor (CRF) receptors (one of many components of the body’s response to stress) in mice that were designed to over-expressed CRF, which happened to cause them to lose their hair as they aged (age being relative for a lab mouse).

courtesy of flickr user ilovememphis (creative commons)

According to a press release from the University of California, Los Angeles (UCLA), Health Sciences, the researchers were actually studying stress and gastrointestinal function, and they noticed hair regrowth as a side effect. “The fact that chronically stressed CRF-OE mice become alopecic in adulthood is reminiscent of human hair loss associated with stress,” the researchers noted.

They reported the findings (with great photos of the mice) this week in the online journal PLoS One. The researchers treated the stressed-out mice (some of which had already developed alopecia in response to chronic stress) with astressin-B, a long-acting peptide and nonselective CRF receptors antagonist. The mice were injected with 5 mcg of astressin-B daily for 5 days.

The mice with hair loss showed skin pigmentation (a sign of the onset of hair growth) within a week of the last injection, and showed no additional hair loss for the next two months. After four months, the mice still had 70% of their hair. In addition, younger stressed-out mice that hadn’t yet started to lose their hair did not lose any.

The researchers also tested astressin2-B. Mice treated with this selective CRF receptor antagonist showed some skin pigmentation after the injection, but still experienced hair loss. Better than minoxidil? Once the researchers noticed the hair growth effect, they treated other stressed-out mice with minoxidil for 10 days for comparison. Hair growth scores increased, but these mice showed visibly less improvement than those given astressin-B.

Although the findings are preliminary, they suggest a new avenue of research for treating alopecia in humans, especially for individuals coping with acute traumatic events or chronic stresses such as chemotherapy, the researchers said. If nothing else, the findings suggest that the stressed-out mice could be a research model for additional studies of stress-related hair loss, the researchers noted.

There was a wonderful article in The Wall Street Journal this week (with video) about doctors who routinely bring their dogs to their offices. The doctors say that the presence of a dog in a doctor’s office often helps patients open up or calm down, as needed.

courtesy of flickr user JohnONolan (creative commons)

Most of the doctors in the story are psychiatrists, who apparently have a history of bringing their pets to work. According to the article, Sigmund Freud often kept his dog (a chow named Jofi) in his office during patient visits, and he observed that the dog had a calming effect on his patients. Several of the contemporary psychiatrists reported similar observations. The dog’s temperament, rather than breed, is what matters. “Canine assistants” described in the article included a shih tzu, a Labrador retriever, cavalier King Charles spaniels, and mutts.

Obviously, some patients who are allergic to or afraid of dogs won’t get any benefit from having them around. So doctors who are considering bringing their pets on staff should warn patients in advance that a dog is present, and keep Fido out of the room as necessary. Dogs don’t have to be certified therapy dogs to help patients relax, but they should be reliably well-behaved. Doctors in other specialties, such as dermatology and plastic surgery, have been known to let their dogs have the run of the waiting room as a way to relax and entertain patients, although treatment rooms are off-limits.

The dogs seem especially valuable for the youngest and oldest patients. One of the doctors in the story, a neurologist who specializes in memory disorders, said that her two dogs put many of her older patients at ease. And one parent said her child actually looks forward to visiting her child psychologist because she loves seeing the dogs.

Having a canine staff member is budget-friendly, too. Dogs don’t need a benefits plan, and they take payment in snacks, walks, and love.